Nursing Care of Clients with Altered Fluid, Electrolyte, and Acid–Base Balance

1. Nursing Care of Clients with Altered Fluid, Electrolyte, and Acid–Base Balance

2. Fluid and Electrolyte Balance • Necessary for life, homeostasis • Nursing role: help prevent, treat fluid, electrolyte disturbances

3. Fluid • Approximately 60% of typical adult is fluid • Varies with age, body size, gender • Intracellular fluid • Extracellular fluid • Intravascular • Interstitial • Transcellular • “Third spacing”: loss of ECF into space that does not contribute to equilibrium

4. Electrolytes • Active chemicals that carry positive (cations), negative (anions) electrical charges • Major cations: sodium, potassium, calcium, magnesium, hydrogen ions • Major anions: chloride, bicarbonate, phosphate, sulfate, and proteinate ions • Electrolyte concentrations differ in fluid compartments

5. Regulation of Fluid • Movement of fluid through capillary walls depends on • Hydrostatic pressure: exerted on walls of blood vessels • Osmotic pressure: exerted by protein in plasma • Direction of fluid movement depends on differences of hydrostatic, osmotic pressure

6. Regulation of Fluid • Osmosis: area of low solute concentration to area of high solute concentration • Diffusion: solutes move from area of higher concentration to one of lower concentration • Filtration: movement of water, solutes occurs from area of high hydrostatic pressure to area of low hydrostatic pressure • Active transport: physiologic pump that moves fluid from area of lower concentration of one of higher concentration

7. Active Transport • Physiologic pump that moves fluid from area of lower concentration to one of higher concentration • Movement against concentration gradient • Sodium-potassium pump: maintains higher concentration of extracellular sodium, intracellular potassium • Requires adenosine (ATP) for energy

8. Fluids Animation

9. Fluid Volume or Electrolyte Imbalance • Causes of fluid loss • Vomiting, diarrhea • Gastrointestinal suctioning, intestinal fistulas, and intestinal drainage • Diuretic therapy, renal disorders, endocrine disorders • Sweating from excessive exercise, increased environmental temperature • Hemorrhage • Chronic abuse of laxatives

10. Fluid Volume or Electrolyte Imbalance • Cause of Fluid Loss in the Older Adult • Self limiting fluids (fear of incontinence) • Physical disabilities • Cognitive impairments • Older adults without air conditioning

13. Fluid Volume Imbalances • Fluid volume deficit (FVD): hypovolemia • Fluid volume excess (FVE): hypervolemia

14. Fluid Volume Deficit • Loss of extracellular fluid exceeds intake ratio of water • Electrolytes lost in same proportion as they exist in normal body fluids • Dehydration: loss of water along with increased serum sodium level • May occur in combination with other imbalances

15. Fluid Volume Deficit (cont’d) • Dehydration • Causes: fluid loss from vomiting, diarrhea, GI suctioning, sweating, decreased intake, inability to gain access to fluid • Risk factors: diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, third space shifts

16. Fluid Volume Deficit (cont’d) • Manifestations: rapid weight loss, decreased skin turgor, oliguria, concentrated urine, postural hypotension, rapid weak pulse, increased temperature, cool clammy skin due to vasoconstriction, lassitude, thirst, nausea, muscle weakness, cramps • Laboratory data: elevated BUN in relation to serum creatinine, increased hematocrit • Serum electrolyte changes may occur

18. Fluid Volume or Electrolyte Imbalance • Treatment for Fluid Volume Deficit (FVD) • Oral, intravenous, or enteral routes • Manage the effects and prevent further complications by monitoring intake, assessing lab values, and observing vital signs and skin integrity

19. Fluid Volume Deficit - Nursing Management • I&O, VS • Monitor for symptoms: skin and tongue turgor, mucosa, UO, mental status • Measures to minimize fluid loss • Oral care • Administration of oral fluids • Administration of parenteral fluids

20. Fluid Volume Excess • Due to fluid overload or diminished homeostatic mechanisms • Risk factors: heart failure, renal failure, cirrhosis of liver • Contributing factors: excessive dietary sodium or sodium-containing IV solutions • Manifestations: edema, distended neck veins, abnormal lung sounds (crackles), tachycardia, increased BP, pulse pressure and CVP, increased weight, increased UO, shortness of breath and wheezing • Medical management: directed at cause, restriction of fluids and sodium, administration of diuretics

21. Fluid Volume Excess - Nursing Management • I&O and daily weights; assess lung sounds, edema, other symptoms; monitor responses to medications- diuretics • Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions • Monitor, avoid sources of excessive sodium, including medications • Promote rest • Semi-Fowler’s position for orthopnea • Skin care, positioning/turning

22. Manifestations of Imbalances • Hyponatremia • Muscle cramps, weakness, fatigue • Dulled sensorium, irritability, personality changes • Hypernatremia • Most serious effects are seen in the brain • Lethargy, weakness, irritability can progress to seizures, coma, and death

23. Manifestations of Imbalances • Hypokalemia • EKG changes (flattened or inverted T waves) • Skeletal muscle weakness • Hyperkalemia • Cardiac arrest • Paresthesias • Abdominal cramping

24. Manifestations of Imbalances • Hypocalcemia • Tetany, paresthesias, muscle spasms • Hypotension • Anxiety, confusion, psychosis • Hypercalcemia • Muscle weakness, fatigue • Personality changes • Anorexia, nausea, vomiting

25. Manifestations of Imbalances • Hypomagnesemia • Muscle weakness and tremors • Dysphasia • Tachycardia hypertension • Mood and personality changes • Hypermagnesemia • Depressed deep tendon reflexes • Hypotension • Respiratory depression

26. Manifestations of Imbalances • Hypophosphatemia • Muscle pain and tenderness • Muscle weakness and paresthesias • Confusion • Manifestations of hypophosphatemia • Muscle spasms, tetany • Soft tissue calcifications

27. Maintaining Acid-Base Balance • Normal plasma pH 7-35-7.45: hydrogen ion concentration • Major extracellular fluid buffer system;bicarbonate-carbonic acid buffer system • Kidneys regulate bicarbonate in ECF • Lungs under control of medulla regulate CO2, carbonic acid in ECF

28. ACID–BASE DISTURBANCES • Plasma pH is an indicator of hydrogen ion (H+) concentration. • Normal range pH (7.35–7.45). • Buffer systems • Kidneys • Lungs • The H+ concentration is extremely important: • Increased concentration H+ • Increased acidity • Lower the pH. • Deceased H+ concentration • Increased alkalinity • Higher the pH. • pH range compatible with life (6.8–7.8)

29. Acid-Base Disorders • Acidosis: hydrogen ion concentration above normal (pH below 7.35) • Alkalosis: hydrogen ion concentration below normal (pH above 7.45) • Metabolic Acidosis: bicarbonate is decreased in relation to the amount of acid

30. Acid-Base Disorders • Metabolic Alkalosis: excess of bicarbonate in relation to the amount of hydrogen ion • Respiratory Acidosis: CO2 is retained, caused by sudden failure of ventilation due to chest trauma, aspiration of foreign body, acute pneumonia, and overdose of narcotics or sedatives • Respiratory Alkalosis: CO2 is blown off, caused by mechanical ventilation and anxiety with hyperventilation

31. Arterial Blood Gases • pH 7.35 - (7.4) - 7.45 • PaCO2 35 - (40) - 45 mm Hg • HCO3ˉ 22 - (24) - 26 mEq/L • Assumed average values for ABG interpretation • PaO2 80 to 100 mm Hg • Oxygen saturation >94% • Base excess/deficit ±2 mEq/L

32. ACID–BASE DISTURBANCES AND COMPENSATION • DISORDER INITIAL EVENT COMPENSATION • Respiratory acidosis ↑ PaCO2, ↑ or normal Kidneys eliminate H+ and HCO3 −, ↓ pH retain HCO3− • Respiratory alkalosis ↓ PaCO2, ↓ or normal Kidneys conserve H+ and HCO3−, ↑ pH excrete HCO3− • Metabolic acidosis ↓ or normal PaCO2, Lungs eliminate CO2, ↓ HCO3−, ↓ pH conserve HCO3− • Metabolic alkalosis ↑ or normal PaCO2, Lungs ↓ ventilation to↑ ↑ HCO3−, ↑ pH PCO2, kidneys conserve H+ to excrete HCO3−

33. IV Site Selection

34. Complications of IV Therapy • Fluid overload • Air embolism • Septicemia, other infections • Infiltration, extravasation • Phlebitis • Thrombophlebitis • Hematoma • Clotting, obstruction